CT-guided stereotactic aspiration of brain abscesses

The effective treatment of intracranial abscess remains controversial. Progress in technology, linked with the development of neuronavigational systems, has made stereotactic aspiration and drainage of intracerebral abscesses effective and valid alternatives to traditional methods, namely, conservative medical treatment or open surgical excision. Between 1995 and 2002, 12 patients at our hospital underwent drainage of intracerebral abscesses under stereotactic guidance. Ten patients had solitary lesions and two had multiple abscesses. The appropriate antibiotic schemes were administered following culture of the aspirated material. The size of the abscess, the mass effect, and response to antibiotic treatment were followed up by repeated CT scans. All patients showed improvement and, at the end of treatment, returned to their previous activities. There were neither deaths nor any postoperative complication. A second aspiration was required in one patient due to recurrence of the abscess. The CT-guided stereotactic aspiration of brain abscesses helps achieve all treatment goals. It drains the contents of the abscess, reduces mass effect, and confirms diagnosis. It is minimally invasive, carries minimal morbidity and mortality, and can be performed on compromised patients under local anesthesia.     

Use of the computerized tomographic scan in the diagnosis and treatment of abscesses

Over a 5 year period, 89 patients underwent one or more computerized tomographic scans to locate an abscess during 92 hospitalizations. The scans were a most sensitive (93 percent), specific (98 percent), and accurate (96 percent) means of abscess detection. Thirty-nine patients had positive scans. Sixteen patients were treated directly by open surgical methods, 1 of whom required percutaneous drainage in the postoperative period for incomplete drainage. An additional 23 patients underwent attempted percutaneous abscess drainage. In 17 patients, drainage was successful. Five patients underwent percutaneous drainage and later required laparotomy, two of whom underwent unavoidable surgical procedures and three surgery for incomplete drainage. Overall, percutaneous abscess drainage was successful in 83 percent. Of 11 deaths, 8 occurred in the group with computerized tomographic scans negative for abscess. Three of these were false-negative scans. Three deaths occurred in the group with scans positive for abscess. All were of patients with hepatic abscesses treated by open surgical drainage, one after failed percutaneous drainage. Twelve patients had multiple organ failure, and 8 of these patients died, for a mortality of 67 percent. The computerized tomographic scan is the diagnostic procedure of choice in the diagnosis of abscesses. In selected patients, percutaneous abscess drainage is also a successful means of abscess treatment and avoids the complications of a laparotomy. The onset of multiple organ failure in the surgical patient should alert the diagnostician to the possibility of a septic focus. The role of early laparotomy in these patients is uncertain. We recommend early use of the computerized tomographic scan in the septic surgical patient. Prompt diagnosis and treatment of abscesses, whether by open or percutaneous routes, may avert the development of multiple organ failure and reduce morbidity and mortality.     

Pyogenic liver abscess: a review of 10 years' experience in management

BACKGROUND: Over the past 15 years, diagnostic and interventional radiology techniques have allowed accurate localization of liver abscesses and image-guided percutaneous drainage. This review examines whether these technical advances improve clinical results and discusses the selection of treatment for patients with liver abscesses. METHODS: Ninety-eight patients were treated for pyogenic liver abscess (PLA) at the Royal Prince Alfred Hospital, Sydney, between January 1987 and June 1997. The hospital records were examined and clinical presentation, laboratory, radiological and microbiological findings were recorded. Associations between these findings and failure of initial non-operative management were determined using odds ratios with 95% confidence intervals. Independent predictors were then determined by logistic regression. This analysis was repeated to determine factors associated with mortality. RESULTS: Cholelithiasis and previous hepatobiliary surgery were the most frequently identifiable causes of PLA, each responsible in 15 patients. All 98 patients were treated with intravenous antibiotics and in 13 patients this was the only therapy. Of the remaining 85 patients, six proceeded straight to laparotomy and 79 had percutaneous drainage, of whom 15 required subsequent laparotomy. Factors predicting failure of initial non-operative management were unresolving jaundice, renal impairment secondary to clinical deterioration, multiloculation of the abscess, rupture on presentation and biliary communication. The overall hospital mortality rate was 8%. CONCLUSION: Pyogenic liver abscess remains a disease with significant mortality. Image-guided percutaneous drainage is appropriate treatment for single unilocular PLA. Surgical drainage is more likely to be required in patients who have abscess rupture, incomplete percutaneous drainage or who have uncorrected primary pathology.     

PYOGENIC LIVER ABSCESS: A REVIEW OF 10 YEARS’ EXPERIENCE IN MANAGEMENT

Background : Over the past 15 years, diagnostic and interventional radiology techniques have allowed accurate localization of liver abscesses and image-guided percutaneous drainage. This review examines whether these technical advances improve clinical results and discusses the selection of treatment for patients with liver abscesses. Methods : Ninety-eight patients were treated for pyogenic liver abscess (PLA) at the Royal Prince Alfred Hospital, Sydney, between January 1987 and June 1997. The hospital records were examined and clinical presentation, laboratory, radiological and microbiological findings were recorded. Associations between these findings and failure of initial non-operative management were determined using odds ratios with 95% confidence intervals. Independent predictors were then determined by logistic regression. This analysis was repeated to determine factors associated with mortality. Results : Cholelithiasis and previous hepatobiliary surgery were the most frequently identifiable causes of PLA, each responsible in 15 patients. All 98 patients were treated with intravenous antibiotics and in 13 patients this was the only therapy. Of the remaining 85 patients, six proceeded straight to laparotomy and 79 had percutaneous drainage, of whom 15 required subsequent laparotomy. Factors predicting failure of initial non-operative management were unresolving jaundice, renal impairment secondary to clinical deterioration, multiloculation of the abscess, rupture on presentation and biliary communication. The overall hospital mortality rate was 8%. Conclusion : Pyogenic liver abscess remains a disease with significant mortality. Image-guided percutaneous drainage is appropriate treatment for single unilocular PLA. Surgical drainage is more likely to be required in patients who have abscess rupture, incomplete percutaneous drainage or who have uncorrected primary pathology.     

CT-guided stereotactic aspiration of brain abscesses

The effective treatment of intracranial abscess remains controversial. Progress in technology, linked with the development of neuronavigational systems, has made stereotactic aspiration and drainage of intracerebral abscesses effective and valid alternatives to traditional methods, namely, conservative medical treatment or open surgical excision. Between 1995 and 2002, 12 patients at our hospital underwent drainage of intracerebral abscesses under stereotactic guidance. Ten patients had solitary lesions and two had multiple abscesses. The appropriate antibiotic schemes were administered following culture of the aspirated material. The size of the abscess, the mass effect, and response to antibiotic treatment were followed up by repeated CT scans. All patients showed improvement and, at the end of treatment, returned to their previous activities. There were neither deaths nor any postoperative complication. A second aspiration was required in one patient due to recurrence of the abscess. The CT-guided stereotactic aspiration of brain abscesses helps achieve all treatment goals. It drains the contents of the abscess, reduces mass effect, and confirms diagnosis. It is minimally invasive, carries minimal morbidity and mortality, and can be performed on compromised patients under local anesthesia.     

Renal and perirenal abscesses in patients with otherwise anatomically normal urinary tracts

PURPOSE: We characterized evaluation, management and outcomes in a group of patients diagnosed with renal and perirenal abscesses who had otherwise anatomically normal urinary tracts. MATERIALS AND METHODS: We reviewed our experience with renal/perirenal abscesses at University of Texas Medical Branch from 1991 to 2002. Treatment was determined by physician preference in each individual. RESULTS: Of 70 patients with renal/perirenal abscesses 26 had otherwise anatomically normal urinary tracts, 24 (92%) had at least 1 possible contributory factor, such as diabetes mellitus, and only 38% had the correct diagnosis at initial presentation. The abscess was intranephric in 39% of cases, intranephric and perinephric in 19%, and perinephric only in 42%. Of the 26 patients 18 were treated with percutaneous drainage or aspiration of the abscess and 12 (66.7%) had positive cultures. Eight of the 12 patients (67%) with positive abscess cultures had the same organism in urine and/or blood. All 26 patients were treated with broad-spectrum intravenous antibiotics. In most patients abscess size influenced additional treatments, such as percutaneous needle aspiration or catheter drainage. None of the patients required open surgical drainage, nephrectomy or nephrostomy tube placement. At a mean followup of 10 months all patients had complete radiographic resolution of the abscess without further complications except 1 who had pyelonephritis and another who was found to have a poorly perfused kidney. CONCLUSIONS: With accurate diagnosis and minimally invasive therapy patients with renal and/or perirenal abscesses and otherwise anatomically normal urinary tracts have excellent functional and anatomical outcomes.     

CT-guided stereotactic aspiration and treatment of brain abscesses

Summary The present study reports our experience with stereotactic puncture, aspiration and drainage of brain abscesses in 24 patients from a series of 34 consecutive cases. In all patients an intracavitary catheter was left in place for external drainage and daily irrigation with antibiotics. The patients received pre- and postoperatively triple broad spectrum antibiotic treatment, associated with low dose steroids and anti-epileptic drugs. Follow-up CT scans showed immediate reduction of the abscess size and gradual diameter diminution of the enhancing ring structure until its disappearance. The clinical presentation, risk factors, aetiology, outcome, bacteriological and CT findings were analysed. Mortality in this series was 4%. The majority of patients (96%) had no or minimal disability according to the Glasgow Outcome Scale. Our results confirm the value of this treatment policy and suggest that the stereotactic technique is a simple and safe method with minimal mortality and morbidity in the treatment of the majority of chronic brain abscesses.     

Improved treatment of intra-abdominal abscess. A result of improved localization, drainage, and patient care, not technique

Outcome in patients with abdominal abscesses treated at the University of Pennsylvania, Philadelphia, between 1973 and 1978 (group 1) was compared with that in patients treated between 1981 and 1986 (group 2). Mortality was less in group 2 patients (21% vs 39% in group 1). The decrease in mortality in group 2 was accompanied by a greater percentage of successful predrainage localization (74% vs 55% in group 1), successful initial drainage (76% vs 55% in group 1), and decreased predrainage organ failure (23% vs 52% in group 1). Because failure of initial drainage and predrainage organ failure were associated with increased mortality, improvement in both of these criteria contributed substantially to the lower mortality in group 2 patients. There were no differences in mortality, in initial success in drainage, or in length of hospital stay when 29 group 2 patients who underwent percutaneous drainage were compared with 37 patients who underwent surgical drainage. Mortality (22% vs 21%) and initial success (78% vs 72%) were similar for patients who underwent surgical and percutaneous drainage, respectively. We conclude that initial success in localization and drainage of the abscess is more important than whether drainage is surgical or percutaneous.     

Abdominal abscess. A surgical strategy

To reassess the role of laparotomy and extraserosal drainage in the treatment of patients with abdominal abscess, we analyzed the course of 79 patients who underwent 97 operations to treat 120 abdominal abscesses during a five-year period. In 66 clinical episodes the abscess was drained by the most direct approach. Sepsis resolved with a single operation In 80% of these patients, five patients (8%) required a second operation for drainage for an abscess, and eight patients (12%) died. In 31 clinical episodes, the abscess was drained by a laparotomy. Sepsis resolved with a single operation in 61% of these patients, seven patients (21%) had a second abscess, six patients (19%) required a second operation to drain a metachronous abscess, and six patients (19%) died. When the location or number of abscesses was diagnosed incorrectly, the success rate of therapy fell substantially. Since most abdominal abscesses can now be accurately diagnosed preoperatively, most abscesses should be drained by a direct approach. Exploratory laparotomy is indicated when preoperative localization is unsuccessful, when sepsis has not resolved after other methods of drainage, or when the patient has a concomitant abdominal condition that must be treated surgically.     

Stereotactic operation for brain abscess

Stereotactic management of brain abscess (stereotactic aspiration with external drainage) was performed in 14 patients. Fifteen abscesses in 14 patients were successfully aspirated by this method. After aspiration of the abscess, all patients underwent external drainage for an average of 14.5 days. No complications during aspiration or during external drainage (such as bleeding or infection, respectively) were encountered in our series. Ten out of 14 patients (71.4%) showed excellent prognosis, and 3 of 14 (21.4%) showed good outcome. Only one patient died after the operation, but this was due to lung cancer. Our operative results are quite satisfactory in comparison with operative results reported by other authors.     

Determinants for successful percutaneous image-guided drainage of intra-abdominal abscess

HYPOTHESIS: Characteristics of intra-abdominal abscess can be used to predict successful outcome for percutaneous catheter drainage (PCD). METHODS: We performed a multicenter prospective study of patients who had intra-abdominal infections treated with PCD and intravenous antibiotics. Multivariate regression analysis determined predictors of successful outcome. RESULTS: The study included 96 patients (59% men; mean +/- SD age, 48 +/- 17 years; mean +/- SD Acute Physiology and Chronic Health Evaluation II score, 7.4 +/- 4.9). Postoperative abscess was present in 53% of patients. Isolated microorganisms included Bacteroides species (17%), Escherichia coli (17%), Streptococcus species (14%), Enterococcus species (10%), and fungi (11%). Single abscesses were present in 83% of patients. Computed tomographic guidance was used for drainage in 80% of patients, and ultrasound was used in 20%. The duration of abscess drainage was less than 14 days in 64%. Complete resolution of the infection with a single treatment of PCD was achieved in 67 patients (70%), and with a second attempt in 12 (12%). Thirty-three patients (34%) had PCD for the resolution of intra-abdominal sepsis prior to an elective, definitive procedure. Open drainage as a result of PCD failure was required in 15 (16%) and was more likely in patients with yeast (P<.001) or a pancreatic process (P =.02). Postoperative abscess (P =.04) was an independent predictor of successful outcome. CONCLUSIONS: Percutaneous catheter drainage of intra-abdominal infections was effective with a single treatment in 70% of patients and increased to 82% with a second attempt. A successful outcome is most likely with abscesses that are postoperative, not pancreatic, and not infected with yeast. Percutaneous catheter drainage is now a commonly used staging method for the resolution of intra-abdominal sepsis prior to corrective operation.     

Liver abscess: a clinicopathological analysis of 82 cases

Liver abscesses are a common pathology in India, but a strategy for effective treatment has not been established. Eighty-two patients with liver abscess were studied over a 4-year period. Clinical features, ultrasound findings, laboratory studies, and outcome of therapy were evaluated. Treatment options were antibiotics alone, needle aspiration, catheter drainage, or open surgical drainage; 51.2% of all abscesses were amebic, 23.2% were pyogenic, and 25.6% had unknown causes. A total of 75.6% of the abscesses were solitary, with 62.2% confined to the right lobe. Pyogenic abscesses were more likely to have anemia, leukocytosis, and deranged liver function. Amebic abscesses tended to have a larger volume. Patients undergoing catheter drainage showed a more rapid reduction in initial abscess volume, whereas resolution of the abscess cavity took longer with antibiotic therapy alone. Ultrasound-guided needle aspiration and catheter drainage are safe and effective in the management of liver abscess. Drug therapy alone may be useful only in select cases.     

Can failure of percutaneous drainage of postoperative abdominal abscesses be predicted?

BACKGROUND: Percutaneous drainage (PD) of complex postoperative abscesses associated with a variety of factors such as multiple location or enteric fistula remains a matter of debate. Accordingly, this retrospective study was designed to determine the predictive factors for failure of PD of postoperative abscess, in order to better select the patients who may benefit from PD. METHODS: From 1992 to 2000, the data of 73 patients who underwent computed tomography (CT)-guided PD for postoperative intra-abdominal abscess, were reviewed. PD was considered as failure when clinical sepsis persisted or subsequent surgery was needed. The possible association between failure of PD and 27 patient-, abscess-, surgical-, and drainage-related variables were assessed using univariate and multivariate analysis. RESULTS: Successful PD was achieved in 59 of 73 (81%) patients. The overall mortality was 3% but no patient died after salvage surgery. Multivariate analysis showed that only an abscess diameter of less than 5 cm (P = 0.042) and absence of antibiotic therapy (P = 0.01) were significant predictive variables for failure of PD. CONCLUSIONS: CT-guided PD associated with antibiotic therapy could be attempted as the initial treatment of postoperative abdominal abscesses even in complex cases such as loculated abscess or abscess associated with enteric fistula.     

The surgical management of pancreatic abscess.

In the past 6 years we have operated on 13 patients with pancreatic abscess. Sepsis recurred in all 12 in whom the primary procedure was closed drainage. Following further surgical debridement of these recurrent abscesses 2 patients had further closed drainage and in 10 the cavities were packed open to heal by granulation. One patient underwent primary open packing which eliminated the pancreatic abscess but the patient subsequently died. Six patients (46%) died: one of lung abscesses after recovering completely from secondary open packing, one of an unsuspected carcinoma of the pancreas after secondary closed drainage and 4 of multiple organ failure after secondary open packing. There were no residual intraabdominal abscesses in any of these at autopsy. Four of those who died had initially presented with catastrophic pancreatitis according to Ranson's criteria and all 3 patients with initial sepsis scores of greater than or equal to 15 died. Open packing, whilst appearing to provide better drainage of pancreatic abscesses than closed drainage does not have a dramatic influence on mortality. Future reports of the results of open and closed methods of treating pancreatic abscesses should take account of both the severity of pancreatitis and of sepsis.     

Pancreatic abscesses

This paper presents the clinical features and problems in the management of 34 patients with pancreatic abscesses. In the majority of patients the abscesses developed following an attack of pancreatitis due to alcohol or gallstones. The abscesses were usually multilocular, and often had spread widely in the retroperitoneal space. Invasion into surrounding viscera or the peritoneal cavity occurred in 12 instances, and eight patients developed major bleeding into the abscess cavity. Obstructive complications (affecting bowel, common bile duct and large veins) occurred in eight patients. Twelve of the 34 patients (35 per cent) died, most deaths being due to failure to control sepsis (seven patients) or to massive bleeding from the abscess cavity (three patients). The mortality of this condition is likely to remain high, but may be reduced by better drainage techniques at the initial exploration. The importance of the infra-mesocolic approach for drainage is emphasized.     

肾周脓肿25例的诊断与治疗

目的：提高肾周脓肿的诊断与治疗水平。方法：回顾性分析25例肾周脓肿患者的临床资料。结果：25例患者明确诊断为肾周脓肿，72％患者尿培养阳性，CT确诊率92％。3例(12％)死亡。10例患者脓肿直径1.8cm，单独使用抗生素治疗平均住院10d；11例脓肿平均直径11cm，采用抗生素联合经皮穿刺引流治疗，平均住院30d；4例最后进行了外科探查和肾切除。结论：肾周脓肿临床变化特点并不典型，CT检查是目前确诊最可靠的方法，通过明确的分期以获得理想的疗效。     

Abdominal wall abscesses in patients with crohn’s disease: Clinical outcome

Abdominal wall abscess due to Crohn’s Disease used to be one of the definitive indications for operative treatment. The advent of interventional radiology, the accessibility to percutaneous drainage, and the availability of new medications raised the possibility of nonoperative treatment of this condition. The clinical presentation, treatment, and follow-up of 13 patients with abdominal wall abscesses secondary to Crohn’s Disease were retrospectively reviewed. During a 10-year period (1993-2003), 13 patients with abdominal wall abscess were treated. Five patients had an anterolateral abdominal wall abscess and eight had a posterior abscess (psoas). In 11 patients, 17 drainage procedures were performed: 12 per-cutaneous and 5 operative. Despite initial adequate drainage and resolution of the abscess, all 13 patients eventually needed resection of the offending bowel segment, which was undertaken in 12 patients. The mean time between abscess presentation and definitive operation was 2 months. Percutaneous drainage is an attractive option in most cases of abdominal abscesses. However, in Crohn’s Disease patients with an abdominal wall abscess, we found a high failure rate despite initial adequate drainage. We suggest that surgical resection of the diseased bowel segment should be the definitive therapy. Presented at a Joint Meeting of the Israeli Society of Colon and Rectal Surgery and Israeli Society of Gastroenterology, Dead Sea, Israel, December 22, 2003.     

Renal and Perinephric Abscesses: Analysis of 65 Consecutive Cases

Objective The objective was to describe the last 10 years’ experience of the diagnosis and treatment of renal, perinephric, and mixed abscesses in an academic reference center. Patients and Methods The medical records of 65 patients with renal, perinephric, and mixed abscesses treated at our hospital from January 1992 to December 2002 were reviewed. The data collected included predisposing factors, symptoms, physical examination, initial diagnosis, laboratory and radiologic evaluation, treatment, and clinical outcome. Results Perinephric abscesses were found in 33 (50.8%) patients, renal abscesses were found in 16 (24.6%), and 16 (24.6%) had mixed abscesses. Urolithiasis (28%) and diabetes mellitus (28%) were the most common predisposing conditions. The duration of symptoms before hospital admission ranged from 2 to 180 days (mean 20 days). Urine culture was positive in 43% of patients and blood culture was positive in 40% of patients. Most of the perinephric abscesses received an interventional treatment: surgical drainage (24%), percutaneous drainage (42%) or nephrectomy (24%). Most patients were cured (73.3%) on discharge from hospital. Mixed (renal and perinephric) abscess treatment was similar: percutaneous drainage (37.5%), surgical drainage (18.75%) or nephrectomy (37.5%). Most patients were cured (60%) on discharge from hospital. Renal abscesses, however, were treated medically in 69% of patients and 73% were cured on discharge from hospital. Conclusions Perinephric and mixed abscesses are successfully managed by interventional treatment. Renal abscesses can be managed by medical treatment only, reserving interventional treatment for large collections or patients with clinical impairment. Early diagnosis is an important factor in the outcome of renal and perinephric abscesses.     

A Prospective Series Case Study of Pyogenic Liver Abscess: Recent Trands in Etiology and Management

Our study aims to review the literature on the management of pyogenic liver abscess, focusing on the choice of drainage. A case series of our experience with clinicopathological correlation is presented to highlight the indication and outcome of each modality of drainage. Intravenous antibiotic is the first line, and mainstay, of treatment. Drainage is necessary for large abscesses, equal to or larger than 5 cm in size, to facilitate resolution. While percutaneous drainage is appropriate as first-line surgical treatment in most cases, open surgical drainage is prudent in cases of rupture, multiloculation, associated biliary, or intra-abdominal pathology. Percutaneous drainage may help to optimize clinical condition prior to surgery. Nevertheless, in current good clinical practices, the choice of therapy needs to be individualized according to patient’s clinical status and abscess factors. They are complementary in the management of liver abscesses.     

Retroperitoneal abscesses--analysis of a series of 66 cases

OBJECTIVE: To analyze our experience with the management of retroperitoneal abscesses. PATIENTS AND METHODS: A retrospective study was made of 66 patients with retroperitoneal abscesses treated at our hospital from January 1975 to July 2001 for the purpose of analyzing the diagnosis and treatment of these rare infections. In each case, we analyzed patient characteristics, abscess location and origin, predisposing factors, clinical presentation, microbiology, radiographic findings, treatment, and outcome. RESULTS: In our series, the most frequent type of abscess was perinephric (45.4%), and the most frequent origin was the kidney (72.7%), generally renal lithiasis or previous urological surgery. Gram-negative bacilli were the microorganisms most often involved as causal agents of abscesses. CT had the best diagnostic performance (95%). Percutaneous drainage resolved the abscess in 86.3% of the patients in which it was used, compared with 87.5% for traditional surgical drainage. In 4 cases, the only treatment was administration of antibiotics. In all these cases the abscesses were smaller than 3 cm and patients were in good general condition. The mortality rate was excellent (1.5%), probably due to the low rate of comorbidity in our patients. CONCLUSIONS: Gram-negative bacilli were the most frequent microorganisms in our retroperitoneal abscesses. CT was the imaging technique that produced the most reliable and rapid diagnosis. Radiographically-guided percutaneous drainage was a safe and effective therapeutic alternative when used as definitive treatment or preoperatively.